GOODS IN TRANSIT CLAIM FORM

THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUANCE OF THIS CLAIM FORM

1. PARTICULARS OF THE INSURED

Name of Insured: ____________________________________________________________________

Policy No: _______________________________________Claim No: __________________________

Address: _________________________________________ Tel No: ___________________________

Place of Occurrence: _________________________________________________________________

Name of Driver: _____________________________________________________________________

Address of Driver: ___________________________________________________________________

Description of Goods Concerned: _______________________________________________________

Circumstances of loss or damage:

……………………………………………………….…………………………………………………………………

……………………………………………………………………………………………….…………………………

……………………………………………………….…………………………………………………………………

……………………………………………………………………………………………….…………………………

Date of Loss: Time: a.m. /p.m.

Total Weight: ___________________________ Total Value: ____________________________

2. IF ANOTHER VEHICLE WAS INVOLVED, NAME AND ADDRESS OF OWNER(S):
___________________________________________________________________________________

___________________________________________________________________________________

(i) If insured, name of Insurance Company: ______________________________________________

(ii) Names and addresses of witness(es): _________________________________________________

(iii) Address of Police Station advised: __________________________________________________

(iv) Address from which goods were dispatched: __________________________________________

Date advised: _______________________________________________________________________

Date dispatched: ____________________________________________________________________

(v) Name and address of consignee(s):

___________________________________________________________________________________

___________________________________________________________________________________

3. PARTICULARS OF GOODS LOST OR DAMAGED:

Quantity Description Value

Total

Value of Salvage

Net loss or Cost of Repairs

Address where damaged goods can be inspected: _________________________________________

4. IF YOU ARE THE OWNER OF THE GOODS, PLEASE COMPLETE THIS SECTION

How and by whom were the goods transported? ___________________________________________

(ii) Have you advised them of the loss or damage? _________________________________________

(iii) Name and address of their insurers: _________________________________________________

Date advised: _______________________________________________________________________

5. IF YOU ARE CLAIMING AS CARRIER OF THE GOODS, PLEASE COMPLETE THIS SECTION:

(i) Name and address of owners of goods: ________________________________________________

(ii) Name and address of their insurers: __________________________________________________

(iii) Were you the principal contractor, or a sub-contractor? ________________________________

(iv) Registered letters and numbers of your vehicle concerned: ______________________________

(v) If your vehicle was unattended when the loss or damage occurred, how was it secured?
___________________________________________________________________________________

(vi) Were they checked by your driver? __________________________________________________

(vii) Did you or your employees load or unload the vehicle? _________________________________

(viii) Did the consignee accept delivery? _________________________________________________

(ix) If so, was a receipt given? _________________________________________________________

(x) What conditions of carriage do you use? (Please attach a specimen copy) ___________________

(xi) Has the claim been made against you by the owner? ____________________________________

(xii) Date received: __________________________________________________________________

(Please attach the Debit Note(s)/ Estimate of loss, if it has been obtained)

CONSENT

I, ………………………………………………………………………………………… (the Data Subject)

hereby affirm that in line with the Nigeria Data Protection Regulation, 2019 (NDPR), I consent to the
collection and processing of my personal data/information (within or outside Nigeria) in the absence
of any fraud, duress, undue influence or coercion for the purpose of this claim and other necessary
data processing activities which may arise therefrom, including for the performance of the insurance
contract between myself and SANLAM General Insurance Nigeria Ltd. I affirm that I have the
requisite capacity under the law to consent to the collection and processing of my personal data.

I further consent to the processing of my personal data, including transfer of my personal data to any
third party for reasons associated with the purpose for which the data is being processed as stated
above or processing for the marketing of SANLAM General Insurance Nigeria Limited’s existing or
future products. I authorize and consent that medical practitioners who may be in possession of, or
hereafter acquire any information pertaining to my medical records may disclose such information to
SANLAM General Insurance Nigeria Limited.

I affirm that I am aware and take cognizance of my rights under the NDPR which include the right to
request for access, amendment, rectification or cancellation or destruction of my personal
data/information, the right to lodge complaint with the relevant authority as well as the right to object
to the processing of my personal data.
I/WE declare that the foregoing answers are true and complete and that I/We hold no other policy
indemnifying me us in respect of this claim. I/We request you to deal on my/our behalf with third party claims
arising herein, in accordance with the terms and conditions of the above mentioned policy. and I/We
authorize you and your solicitors on my/our behalf to make such admissions and settlements and give such
consents as you may consider necessary for the disposal of such claims and any litigation arising therefrom

Date Insured’s Signature